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The preliminary infant mortality rate for 1996 in the United States was 7.2 deaths per 1000 live births, a 5 percent reduction from 1995 (7.6), according to the National Center for Health Statistics (Month Vital Stat Rep 1997;46(1 supp 2): 1–6). The leading cause of infant deaths was congenital anomalies (almost 23%). The second leading cause was disorders relating to short gestation and low birthweight, and the third was SIDS (10%), which declined almost 15 percent from 1995. Prenatal care use improved again for 1996, rising to 81.8 percent, and the percent of mothers with late or no prenatal care declined to 4.1, according to preliminary data. The birth rate for teenagers dropped 4 percent in 1996, to 54.7 births per 100 women aged 15–19 years; the teenage birth rate declined from 62.1 percent since 1991. The overall rate for low birthweight increased slightly from 7.3 percent in 1995 to 7.4 percent in 1996.

A new campaign to increase breastfeeding rates by changing public attitudes was initiated in August 1997 by the U.S. Department of Agriculture (USDA) through the special supplemental nutrition program for Women, Infants, and Children (WIC) (Nation's Health 1997:Sept:36). With 45 percent of U.S. babies served by WIC, the USDA “has direct access to get the breastfeeding message to new mothers,” said USDA Secretary Dan Glickman. WIC staff have long advocated breastfeeding because of its many benefits to infant and mother, but studies have shown that many WIC clients are reluctant to breastfeed because they are embarrassed or lack family support. The new campaign coordinates mass media advertising, client education materials, staff training and community outreach promoting the theme, “Loving support makes breastfeeding work.” Campaign materials mention the health benefits of breastfeeding and emphasize its emotional rewards, such as closeness between mother and child and family solidarity. Leaflets clearly state that breastfeeding “works best when dad, family, friends, and the community offer support.” The campaign began with 10 pilot projects sponsored by WIC agencies. For a price list of campaign materials, call (800) 277–4975.

Infants born to mothers living next to a New Jersey landfill at the height of its activity had substantially lower birthweights and twice the risk of being born prematurely as their unexposed counterparts, according to a study conducted by the New Jersey Department of Health and Senior Services (Nation's Health 1997; Oct:8). The study was based on birth records of residents of four municipalities bordering on the Lipari landfill, which was backfilled with municipal, household, and industrial wastes from 1958 to 1971, when operations ended because of complaints. Between 1971 and 1975, the period of heaviest runoff of hazardous material, babies within a 1 km radius weighed on average about 2.5 ounces less at birth than their unexposed counterparts beyond the radius. Those whose babies were adjacent to the landfill were almost 7 ounces lighter and were five times as likely to be categorized as low birthweight and twice as likely to be born preterm. Other explanations, such as economic or cultural differences, were ruled out. Lead investigator, Michael Berry, noted that living at the very edge of the site was significantly more hazardous than living several blocks away. He suspects that the pregnancy problems resulted from breathing fumes from industrial compounds such as benzene and methylene chloride, which were dumped in large quantities during the 1970s. The study was partly funded by the federal Agency for Toxic Substances and Disease Registry.

Higher rates of dental caries and lower rates of saliva occurred in pups born to female rats that had been raised on drinking water containing high concentrations of lead (34 ppm) (Science News 1997;152:149). The investigation of maternal transmission of lead in rats was conducted by William Bowen, a dentist and microbiologist, and researchers at the University of Rochester (NY) School of Medicine and Dentistry. He noted that a big drop has occurred in the prevalence of childhood caries, but of those cases, “some 80 percent are occurring in just 20 percent of kids,” mostly those living in inner cities. Because lead mimics calcium, the body normally stores most lead in bone. During pregnancy and lactation, when the body breaks down bone to liberate calcium for the developing young, lead can be released back into the blood. “We know that lead crosses the placenta,” Bowen said, “so there was good reason to suspect it could affect [tooth] development.” The researchers reported that pups from lead-exposed mothers developed 40 percent more dental cavities and produced 30 percent less saliva than did pups born to mothers raised on lead-free water, two findings that might be related. The Rochester study also “found surprisingly high levels of lead in ]breast] milk,” at concentrations roughly 10 times as high as those in the rat mothers' blood. “This indicates that there is clearly some concentrating mechanism” in mammary tissue,” Bowen said.

The release of the Linked Birth/Infant Death Data Set-1995 period data file by the National Center for Health Statistics on public-use data tape will permit analysis of many variables available from the birth and death certificates for infants born in the United States. The CD-Rom version became available in January 1998. Some variables included in the data set are race and age of mother and father, marital and educational status of mother, age at death, medical risk factors, smoking and alcohol use by mother during pregnancy, obstetric procedures, birthweight, gestational age, parity, prenatal care, complications of labor/delivery, method of delivery, abnormal conditions of the newborn, and underlying and multiple causes of death. The complete data set (4 tapes) costs $1300. For information contact Data Dissemination Branch, 6525 Belcrest Road, Room 1064, Hyattsville, MD 20782–2003; tel (301) 436–8500; Internet: http://www.cdc.gov/nchswww/nchshome.htm.

A maternal death resulting from a rare invasive Group A streptococcus infection occurred in March 1997 at a university teaching hospital in upstate New York (Rochester Democrat & Chronicle Oct 4, 1998:1A). Maternal deaths are uncommon in the United States—277 women (7.1 deaths per 100,000 live births) died from complications of pregnancy, childbirth, and the puerperium in 1995 (Month Vital Stat Rep 1997;45(11 supp 2):13). In the reported case, the 39-year-old mother gave birth to a healthy baby girl, her third by cesarean section, on February 17, and she died two weeks later. The investigation by the New York State Department of Health cited four violations for deficiencies in the care provided by the hospital to two obstetric patients (one survived) with the infection, and found that the hospital “did not meet acceptable standards or practice” or its own protocols. Findings included the following: Neither the mother's obstetrician, nor anyone from his group practice, saw the mother for 60 hours after her cesarean section. A delay occurred in recognizing the severity of the mother's condition and aggressive treatment was not initiated on a timely basis. No cardiac monitor or defibrillator was on the maternity unit, and when the woman's heart stopped, it took 10 minutes to locate the equipment and get it to her room. Staff were not familiar with the contents of the emergency “crash cart.” Despite the mother's known allergy to latex, staff used a latex tourniquet to draw blood and a latex drain during surgery. Additional findings were listed for the second woman who lived. The state health department fined the hospital $8000, or $2000 for each violation, to be waived when the official plan of corrective action was accepted by the hospital. The hospital submitted the corrective plan to the state in October 1997 and the state suspended the fine. In addition to implementing the corrections, the hospital must submit quarterly progress reports to the state health department. It was reported that the woman's family may take legal action against the physician if the health department does not impose disciplinary measures.

Eight hospitals have been designated “Baby Friendly” in the United States (Gold Standard Oct, 1997). They are Evergreen Hospital (Kirkland, WA); Kaiser Permanente Medical Center (Honolulu, HI); Reading Birth Center (Reading, PA); Alice Peck Day Hospital (Lebanon, NH); Miles Memorial Hospital (Damariscotta, ME); Mid-Michigan Regional Medical Center (Midland, MI); Franciscan Hospital, MOM Center (Cincinnati, OH); and Goleta Valley Cottage Hospital (Santa Barbara, CA). More than 300 hospitals have obtained a “certificate of intent,” which involves a self-study of hospital practices to determine if they comply with the Ten Steps to Successful Breastfeeding.

Lamaze International is the new name for the childbirth education organization formerly known as ASPO/Lamaze (Lamaze Int Update Fall 1997). However, it will continue to use the ASPO/Lamaze name in connection with its certification program. The change reflects the group's new educational direction and activities, and ASPO/Lamaze “no longer describes what we do or who we are as an organization.” The group also notes that “Lamaze” has better name recognition than the former name. Pointing out that psychoprophylaxis means “mind prevention,” Mary Jo Podgurski, Lamaze International President, said, “While we certainly continue to teach some distraction techniques in Lamaze classes, more often we encourage women to ‘tune in' to the wonderful, powerful work that their bodies are doing.” The new name also reflects the expansion of the organization into countries such as Canada, Mexico, and Russia, and its desire to continue to extend its programs beyond the United States.

Edwin Cragin's name and his dictum, “Once a Caesarean always a Caesarean,” has become synonymous with the repeat cesarean section policy that was formerly standard practice in the United States. His name, however, has been consistently misspelled by authors, from an early reference to him in the 1981 National Institutes of Health Consensus Development Conference report, Cesarean Childbirth, to numerous articles in peer-reviewed journals over the years. A recent perusal of the Birth editor's files, in fact, revealed three misspellings of his last name—Craigin, Craigen, Cragen—and reference to him incorrectly by the first name of Edward. The quotation itself, taken from his article, “Conservatism in Obstetrics” (NY Med J 1916; 104:1–3) has also been incorrectly given as “Once a cesarean section, always a cesarean section” and “Once a cs, always a cs,” and it is always spelled as “cesarean” rather the original spelling of “caesarean.” Of course, tracking down Cragin's 1916 paper is not easy, because no index of medical journals was published at the time. What does Dr. Edwin Cragin actually say?

One thing must always be borne in mind, viz., that no matter how carefully a uterine incision is sutured, we can never be certain that the cicatrized uterine wall will stand a subsequent pregnancy and labor without rupture. This means that the usual rule is, once a Caesarean always a Caesarean (italics in the original). Many exceptions occur.…

It is easy to see how such quotation errors are perpetuated from one journal or book to another when authors fail to search out the original reference.

International News

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A review of maternity services and its progress in the United Kingdom by the Audit Commission was published in 1997, entitled, First Class Delivery: Improving Maternity Services in England and Wales (Changing Childbirth Update 1997;9:12). The Audit Commission, which oversees the external audit of the National Health Service (NHS) and local authorities and makes recommendations for improving the economy, efficiency, and effectiveness of services, collected information from 13 NHS trusts, over 2000 recent mothers, 12 commissioning authorities, and 300 general practitioners. Key findings included the following:

• Most women rated maternity care very positively

• Women wanted more and better information about services and care options

• Care by midwives should be organized to ensure continuity of caregiver to women in labor

• Problems with hospital postnatal care should be addressed

• Staff should be deployed more flexibly to match fluctuating demand on labor wards

• Specialist hospital care should be targeted where it is most needed

• Clinicians need access to training and education to keep up-to-date with changing practice

• Medical intervention levels should be kept under constant review for appropriateness

• Views of service users should be taken into account when planning services, together with cost and effectiveness issues

• Clinical guidelines and protocols should be developed

Health care was substandard in eight out of 10 cases of women who died from hypertensive disorders of pregnancy in the United Kingdom, according to a government report on maternal deaths, Report on Confidential Enquiries Into Maternal Deaths in the United Kingdom, 1991–1993 (Safe Motherhood 1997;23:2). Hypertensive disorders are the second cause of maternal death in the U.K., although numbers fell by a third in the three years (1991–1993) covered by the report. Common features of substandard care included errors in diagnosis, inappropriate treatment, and failure to refer patients to senior staff or specialists. The report also pointed to an increase of maternal deaths attributable to anesthesia. Overall the death rate from conditions directly due to pregnancy fell for the first time in a decade and is now 5.5 deaths per 100,000 live births. The leading cause of maternal death is thrombosis and thromboembolism. In the United States the maternal mortality rate was 7.1 and 8.3 deaths per 100,000 live births in 1995 and 1994, respectively (Month Vital Stat Rep 1997;45(1 supp 2): 13).